Background
Identifying Racial and Ethnic Disparities in
Admissions for Ambulatory Care Sensitive
Conditions among Medicare Beneficiaries
Presented by
Arthur J. Bonito, Ph.D.1; Celia R. Eicheldinger, M.S.1;
Arthur A. Meltzer, Ph.D.2, And Linda G. Greenberg, Ph.D.3
1RTI International; 2CMS; 3 AHRQ
Presented at
The 2005 Annual Research Meeting of AcademyHealth,
Boston, MA, June 28, 2005
3040 Cornwallis Road
Phone 919-541-6377
■
z
Limited information and few previously published
studies exist on access to care for minority Medicare
beneficiaries, other than African Americans, using
Medicare administrative claims data.
z
CMS sponsored this project to improve identification of
Asians and Hispanics, as well as to examine disparities
in health care access and use under Medicare.
z
Avoidable hospitalizations for ACSCs provide one
indication of limited access and receipt of less-thanadequate primary care.
P.O. Box 12194 ■ Research Triangle Park, NC 27709
Fax 919-990-8454
e-mail ajb@rti.org
RTI International is a trade name of
Research Triangle Institute
2
Ambulatory Care Sensitive Conditions
Study Goals
Hospital or Emergency Room (ER) admissions for 15
Ambulatory Care Sensitive Conditions (ACSCs) that
include the following :
z
Chronic (5) – chronic lung disease (asthma and
COPD), congestive heart failure, seizures,
diabetes, and hypertension
z
Acute (8) – cellulitis; bacterial pneumonia; urinary
tract infection; ulcers; hypoglycemia; hypokalemia;
dehydration; ear, nose, and throat infections
z
Preventable (2) – influenza and malnutrition
3
To improve accuracy of racial/ethnic identification of
Medicare beneficiaries to include: non-Hispanic
White, Black, Hispanic, Asian/Pacific Islander (A/PI),
and American Indian/Alaska Native (AI/AN).
To identify racial/ethnic disparities in hospital or
emergency room admissions for ACSCs.
4
Methods and Data
Data Limitations
Developed algorithm to more correctly identify Medicare
beneficiaries’ race/ethnicity:
z Used Spanish and Asian surname lists from US Census.
z From Medicare enrollment database (EDB), used first and
last name, race/ethnicity, language preference and place
of residence.
z Used common first names from web sources.
CMS obtains race/ethnicity data on Medicare
beneficiaries from SSA, which categorizes “Hispanic”
as a race code.
We present findings for AI/ANs despite underidentification on the EDB.
Used Medicare Part A claims for 2002 to estimate hospital
and ER admissions for ACSCs.
z
CMS has been working with IHS since 1999 to
improve identification of AI/AN beneficiaries.
Selected a stratified random sample of 1.96 million FFS
Medicare beneficiaries (over-sampling minorities).
z
Analyses show small predictable bias.
5
6
1
2002 Medicare FFS Study Sample
Race/Ethnicity
Sample
Medicare FFS
NH White
329,954
26,779,400
Black
328,246
3,053,618
Hispanic
534,196
720,664
A/PI
415,190
449,914
AI/AN
120,557
121,818
Other/Unknown
231,978
471,630
TOTAL
1,960,121
31,579,044
Analysis Approach
7
We examined hospital or ER admissions for each type of
ACSC - chronic, acute, preventable, and any.
We examined percentages with hospital or ER admission
by type of ACSC, race/ethnicity, sex, and age group.
The following tables include stacked bar graphs for each
type of ACSC by race, sex, and age.
8
Figure 1
Percentage of male Medicare beneficiaries with admissions for chronic
ambulatory care sensitive conditions by age group and race/ethnicity: CY 2002
Figure 2
Percentage of female Medicare beneficiaries with admissions for chronic
ambulatory care sensitive conditions by age group and race/ethnicity: CY 2002
5.95
6.70
5.53
6.00
5.60
85+
4.63
4.85
5.07
6.62
75-84
85+
5.00
75-84
5.49
65-74
4.83
< 65
3.54
4.99
4.12
3.43
4.53
3.05
2.46
5.06
3.50
2.94
2.50
3.72
2.54
1.44
6.78
4.50
White
4.48
Black
Hispanic
A/PI
5.44
5.09
3.70
White
AI/AN
Black
2.22
Hispanic
7.22
4.04
A/PI
AI/AN
Race/Ethnicity
Race/Ethnicity
9
4.79
1.41
8.19
5.83
65-74
< 65
5.52
10
Figure 3
Percentage of male Medicare beneficiaries with admissions for acute
Preliminary Results for Chronic ACSCs
ambulatory care sensitive condition by age group and race/ethnicity: CY 2002
Across all race/ethnicity groups, women have higher
percent of admissions for chronic ACSCs than men.
Typically, men and women under age 65 have higher
percent of admissions for chronic ACSCs.
Among elderly men and women (65 years of age and
over), admissions for chronic ACSCs increase with
age.
9.98
5.98
5.69
5.42
4.46
4.38
3.82
85+
75-84
65-74
< 65
7.07
A/PI and White beneficiaries have lowest percent of
admissions for chronic ACSCs, Blacks and AI/ANs
have the highest percent, Hispanics falls in between.
3.68
4.01
3.14
2.24
2.43
2.51
1.38
4.25
5.02
White
Black
4.04
Hispanic
5.22
3.20
A/PI
AI/AN
Race/Ethnicty
11
12
2
Figure 4
Percentage of female Medicare beneficiaries with admissions for acute
ambulatory care sensitive condition by age group and race/ethnicity: CY 2002
Preliminary Results for Acute ACSCs
Across all race/ethnicity groups, women have higher
percent of admissions for acute ACSCs than men.
Men and women age 85 and over have highest
percent of admissions for acute ACSCs.
Among elderly men and women, admissions for acute
ACSCs increase with age.
A/PI beneficiaries have lowest percent of admissions,
Blacks and AI/ANs have the highest, and Whites and
Hispanics fall in between.
9.38
7.42
6.50
5.61
6.44
85+
75-84
65-74
< 65
5.19
4.73
4.06
3.91
2.71
3.31
4.23
1.52
5.82
White
7.17
Black
5.27
Hispanic
5.00
2.34
7.93
3.93
A/PI
AI/AN
Race/Ethnicity
13
14
Figure 5
Percentage of male Medicare beneficiaries with admissions for preventable
Figure 6
Percentage of female Medicare beneficiaries with admissions for preventable
ambulatory care sensitive condition by age group and race/ethnicity: CY 2002
ambulatory care sensitive conditions by age group and race/ethnicity: CY 2002
0.10
0.15
0.14
0.11
0.11
0.08
0.09
0.09
0.10
White
0.06
0.10
65-74
< 65
0.04
0.04
0.04
0.05
0.03
0.03
0.10
Black
0.12
0.01
0.05
0.04
Hispanic
A/PI
0.04
0.07
0.03
0.09
75-84
0.13
0.08
0.04
0.04
85+
85+
75-84
65-74
< 65
0.08
0.21
0.06
0.03
0.03
0.06
0.10
0.15
0.10
0.06
White
AI/AN
Black
15
Hispanic
A/PI
AI/AN
Race/Ethnicity
Race/Ethnicity
16
Figure 7
Percentage of male Medicare beneficiaries with admissions for any
Preliminary Results for Preventable ACSCs
ambulatory care sensitive condition by age group and race/ethnicity: CY 2002
Across all race/ethnicity groups, women have a higher
percent of admissions for preventable ACSCs than
men.
13.00
Typically, among men and women – ages 85 and over
and under 65 – have the highest percent of admissions
for preventable ACSCs.
10.84
10.14
14.42
9.87
9.90
8.10
17
Typically, among elderly men and women, admissions
for preventable ACSCs increase with age.
7.23
85+
75-84
65-74
< 65
7.67
8.16
7.89
5.17
5.30
4.56
2.96
A/PI beneficiaries have lowest percent of admissions,
Blacks and AI/ANs have the highest, and Whites and
Hispanics fall in between.
11.05
7.76
White
Black
9.79
7.59
6.41
Hispanic
A/PI
AI/AN
Race/Ethnicity
18
3
Figure 8
Percentage of female Medicare beneficiaries with admissions for any
Preliminary Results for any ACSCs
ambulatory care sensitive condition by age group and race/ethnicity: CY 2002
14.02
11.59
75-84
10.36
11.38
Men and women ages 85 and over have highest percent of
admissions for all ACSCs combined.
Among elderly men and women, admissions for all ACSCs
combined increase with age.
A/PI beneficiaries have lowest percent of admissions,
Blacks and AI/ANs have the highest, and Whites and
Hispanics fall in between.
65-74
< 65
9.23
7.37
Across all race/ethnicity groups, women have higher
percent of admissions for all ACSCs combined than men.
14.63
85+
11.09
7.49
9.21
6.57
4.93
9.10
4.78
3.02
14.20
White
13.49
9.66
9.56
Black
Hispanic
7.40
A/PI
AI/AN
19
20
Summary of Preliminary Results
21
Conclusions
There is considerable consistency across the 15 individual
ACSCs and the four grouped -- chronic, acute, preventable
and any -- with respect to racial/ethnic differences in the level
of hospital or ER admissions, with age and sex controlled.
The improved race/ethnicity variable indicates sizeable and
consistent differences in admissions for ACSCs, suggesting
differences in access by some minority groups to timely and
appropriate primary care services.
z
Black and AI/AN beneficiaries have the highest levels of
ACSC hospital or ER admissions.
z
A/PI beneficiaries have the lowest level of ACSC hospital
or ER admissions.
More accurate coding for Hispanics and A/PIs allows a
unique opportunity to increase our knowledge of disparities
in health care use and outcomes.
z
Hispanic and White beneficiaries typically occupy the
middle ground, with lower levels of ACSC hospital or ER
admissions than Black and AI/AN, but higher than A/PI.
Additional research is needed, including multivariate
analysis to adjust for differences in SES, health status,
disease levels, as well as hospital, ER, outpatient, and
ambulatory care service use.
22
4
0
